Putting research into practice

Behavioural scientist Associate Professor Chris Paul learned some important lessons about health research implementation very early on in her career.

“We made one of the classic mistakes in that we didn’t really talk to the people who were the end users of our findings when we started.”

“Looking back now I can see how naïve I was.

“I thought I’d l find the answer to a question and then people would implement my discoveries. But that’s not what happens.”

As part of her PhD project, Chris compared how different health information pamphlets were received by their intended audience. Whereas some of the material had been prepared following traditional graphic design guidelines, others had been made to contravene design and information principles.

Contrary to her initial hypothesis, there was no real difference in how the information was interpreted, despite there being a lot of variation in the pamphlets’ design.

“We hadn’t really been talking to the developers of the content – if we had then we would have known that when we actually had our results that they would effectively reject them.

“And that’s just the way it is.

“You can’t just drop a finding on people who are very invested in doing something in a certain way.

“They have to actually come on the journey with you.”

Since those early days, Chris has gone on to conduct research alongside with a number of health service providers and policy makers – a way of ensuring that her work is sufficiently translated into practise.

Her current collaborators include the Cancer Councils of NSW and Victoria, Hunter Cancer Research Alliance (HCRA), NSW Ministry of Health, Cancer Institute NSW, Baker IDI Heart and Diabetes Institute, Aboriginal Community Controlled Health Services, Diabetes WA, National Stroke Foundation and many clinicians across Australia, the United States and United Kingdom.

Currently, Chris is focussed on a number of projects running in cooperation with Cancer Councils.

“Those projects have been founded out of mutual interest.

“We sat down and had discussions about what they were interested in doing and asked ourselves what we could bring to that.

“We’re making sure that we’re answering questions that they want to answer.”

Communication and cancer consultants

At the moment, Chris’ research team is focused on the Cancer Council’s flagship 13 11 20 Cancer Information and Support Service (CISS). As part of one particular project, they are researching the differences between talking to a CISS consultant and typing to one.

While an increasing number of health support services are opting to provide an online instant messaging, or ‘chat’, option, there is little research into how best to adapt traditional telephone practises for this new channel.

“For structured health intervention strategies, like cognitive behavioural therapy, there’s plenty of evidence which supports the idea that online services, when conducted well, can be just as successful as face to face interactions.

“But for something broader, like the services provided by CISS, there are particular things which remain a challenge. There’s very little research around how to convey emotional information for example. There’s not much evidence for how to best modify a phone conversation to an online chat conversation.”

In order to address these questions, Chris is in the process of conducting a trial comparing the outcomes of the two types of service.

“We’ll also look at the content of the conversation to see what was different about the types of interactions.”

Running in parallel with this project, Chris is investigating the different approaches to mental health assessment used by clinicians and CISS consultants.

“There’s this preconception in clinical circles that because clinicians have a lot of professional skills, they’ll all have the ability to have a conversation with someone and get through to a point where they can identify whether they might be depressed or anxious.

“But that’s not as consistent across individual clinicians as you might expect. There's actually a strong evidence base around the value of doing things in a very defined way.

“If health care providers use some scales which are valid for identifying depression or anxiety, and questions are asked consistently in the same kind of way, they get a much better result.”

Chris is interested in seeing whether this evidence from traditional clinical practise will also translate to the setting of the CISS.

“While the consultants are quite used to being attentive to silences or tone of voice, we want to see whether using a structured approach would be beneficial.”

“(The Cancer Council) are actually being very forward thinking in that they are taking something from a clinical setting and asking if that works in their community setting. They're being very worldly in that way .”

Another project is designed to empower cancer patients to quit smoking. The project involves seven hospitals across NSW and is helping oncology clinics to translate the evidence of smoking cessation into practice.

“Currently many patients are not aware that if they quit smoking after their diagnosis they are more likely to cope better with treatment and get a better outcome. Not all cancer patients receive the support they need to quit, but this is one of the Cancer Institute NSW Top 10 implementation science research ‘gaps’ that we’ve been working on with colleagues across the state,” Chris adds.

Solariums, sun damage and skin cancer

Throughout her career as a behavioural scientist, Chris remembers her work with the NSW Solaria Compliance Working Group as being one of the highlights.

Chris was working with the Cancer Council, researching sun protection and skin cancer in the 1990s and the field was becoming increasingly overwhelmed with evidence linking regular solarium use to skin cancer development.

At the time, there was a voluntary standard of practise wherein solarium providers would inform customers of the health risks involved with sun bed usage.

“Cancer Council NSW funded us to us to do some simulated customer research. We sent people into those commercial establishments to ask questions about the sun beds and make an appointment to use them.

“The results of our study, and a number of others which came out later, all pretty much told the same story - that the voluntary standards weren't being followed.”

Chris’ research marked the beginning of the end of commercial solaria in NSW.

In an attempt to stall government regulation, the Solarium Association proposed a trial period wherein they would work with their members to foster a culture of responsibility and appropriate customer care.

When Chris and her collaborators repeated their research a few years later however, they observed no change in practise.

“That put the state government in the position where they were able to regulate against solaria.”

At this time, 26-year-old Clare Oliver, who had been diagnosed with melanoma and attributed her cancer to regular solarium use, came forward with her story. Her willingness to speak publicly about her situation arguably catalysed legislative reform, with the support of research by the UON team and others.

“When you put the research and that kind of story like Clare’s together, that's what really brings policy makers to the point of being prepared to change legislation.”

Career Summary

Biography

A/Prof Chris Paul is an NHMRC Career Development Fellow with the School of Medicine and Public Health, Priority Research Centre for Health Behaviour and Hunter Medical Research Institute. Chris is a behavioural scientist with considerable experience in the development and evaluation of strategies for achieving behavioural change on an individual, system and population level. Her work spans preventive health issues and provision of patient care. Much of her early work was focused on cancer prevention and tobacco control, with an emphasis on the dissemination and adoption of effective behaviour change strategies. She retains a strong interest in cancer prevention and control, with a growing research portfolio relating to each of social disadvantage, chronic disease and health service delivery. Recent work involves applying behavioural approaches to challenges to large multi-site intervention studies in the fields of addiction, diabetes care, stroke treatment with and improving health among disadvantaged groups including Aboriginal and Torres Strait Islander peoples. Throughout her career she has worked closely with Industry groups such as Cancer Councils.

Research TranslationChris was awarded the prestigious National Heart Foundation Rudolf Gerstl Research Award for her proposal of a randomised controlled trial of the telemarketing of telephone support for smokers. This study gave rise to both academic and public sector interest in this innovative approach for Quitlines and other health-related telephone support services. A series of bi-ennial state-wide community surveys on cancer-related issues were used to successfully advocate for legislative changes in NSW such as bans on smoking in public places, bans on smoking in cars and the licensing of tobacco retailers. A quasi-experimental study of organisational change strategies for improving hospital-based smoking care has been used as a model for improving smoking care in hospitals. An exploration of solarium operations via simulated customers which was the first rigorous work demonstrating poor compliance with standards, followed by a later study showing no improvement in practices over time. This was one of several keys to successful efforts to regulate the solarium industry in Australia. Conducting applied research which is both relevant to practice and policy is one of the hallmarks of Chris's work to date.

Research Training

Chris places a strong emphasis on training research higher degree students, with a number of her students being awarded postdoctoral fellowships and research awards, including Faculty awards such as 'ten of the best' and Research Higher Degree Excellence Awards. Chris has also been nominated for and received awards for RHD student supervision.

Teaching ExpertiseChris has written courses and curricula including the Cancer Control module of the Master of Public Health, RACOG Behavioural Medicine Unit and Interactional Skills for undergaduate students in the Faculty of Health. She continues to teach interactional skills and cancer control. Teaching of postgraduate research students continues to be a major focus of her work.

CollaborationsChris is a strong collaborator with a long history of research projects in common with researchers across a range of disciplines. Current collaborators include: colleagues from Canada (Profs Jeremy Grimshaw & Sharon Straus), the US (Prof Jacobsen, Prof Mohammad Siahpush), and the UK (Profs Robert West & Susan Michie). National collaborations include a role as behavioural lead on projects involving: leading researchers in Indigenous health and diabetes -Profs Sandra Eades, Jonathan Shaw, Paul Zimmet (Baker IDI) and Leon Piterman (Monash University) regarding diabetes care in Aboriginal Community Controlled Health Services and rural general practices; leading mental health researchers including Profs Brian Kelly, Amanda Baker,(University of Newcastle), regarding psychosocial support for lung cancer patients; and leading stroke researchers including Profs Chris Levi regarding implementing best practice stroke care.

Qualifications

PhD, University of Newcastle

Keywords

Indigenous health

access to care

behavioural science

cancer prevention

cancer services

communication skills

diabetes

health behaviour

health inequality

health promotion

health services

implementation science

interactional skills

patient care

public health

quality of care

social disadvantage

solar protection

stroke

tobacco control

Fields of Research

Code

Description

Percentage

110399

Clinical Sciences not elsewhere classified

15

111299

Oncology and Carcinogenesis not elsewhere classified

30

111799

Public Health and Health Services not elsewhere classified

55

Professional Experience

UON Appointment

Title

Organisation / Department

NHMRC Career Development Fellowship

University of NewcastleSchool of Medicine and Public HealthAustralia

Academic appointment

Dates

Title

Organisation / Department

Researcher - NSW Cancer Council Tobacco Retailer Strategy Committee

NSW Cancer CouncilAustralia

Advisor - Skin Cancer Research Funding

The Cancer Council NSW University of Wollongong Skin Cancer Reference GroupAustralia

Advisor and Research Director- NSW 45 & up study cancer group

The Sax Institute

Advisor - Tobacco Research and Evaluation Committee

NSW Department of Health

1/01/2009 -

Senior Research Academic

University of NewcastleHealth Behaviour Research Group- School of Medicine and Public HealthAustralia

1/04/2003 - 1/06/2003

Acting Director

University of Newcastle - Centre for Health Research & Psycho-oncologyAustralia

1/01/2003 - 1/12/2004

Consultant

Sax InsituteAustralia

1/11/1999 -

Senior Research Academic

University of Newcastle - Centre for Health Research & Psycho-oncologyAustralia

1/11/1999 - 1/12/2009

Research Academic

The Cancer Council NSWCentre for Health Research & Psycho-oncologyAustralia

Fradgley EA, Paul CL, Bryant J, 'A systematic review of barriers to optimal outpatient specialist services for individuals with prevalent chronic diseases: What are the unique and common barriers experienced by patients in high income countries?', International Journal for Equity in Health, 14 (2015) [C1]

Introduction and Aims.: Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that... [more]

Introduction and Aims.: Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that target comorbidities. The current study aimed to examine sociodemographic characteristics and mental health comorbidities associated with the odds of using tobacco and harmful levels of alcohol concurrently. Design and Methods.: Data were drawn from the 45 and Up Study, a large cohort study with 267153 adults aged 45 years and over in New South Wales, Australia. Participants completed a survey assessing alcohol, smoking, psychological distress, treatment for depression and anxiety, and a range of socioeconomic status indicators. Univariate analyses and three multiple-logistic regression models were used to determine associations with (i) tobacco but not alcohol use; (ii) alcohol but not tobacco use; and (iii) concurrent tobacco and risky levels of alcohol use. Results.: Being female, younger, lower individual and area-level socioeconomic status (SES) and depression and psychological distress were associated with tobacco use alone. Factors associated with alcohol use alone were older age, male gender, higher SES, and lower psychological distress and no recent depression treatment. Factors associated with concurrent risky alcohol consumption and tobacco use included being 45-64, being male, less education, earning

Objectives: To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; ... [more]

Objectives: To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth. Design: A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups. Data sources: MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each database's inception published prior to March 2014. Study selection: Studies that provided either qualitative or quantitative (ie, longitudinal, crosssectional or cohort surveys) descriptions of selfreported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included. Data extraction: Two authors independently assessed studies for inclusion and extracted data. Results: 65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco). Conclusions: Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social networklevel interventions are priority areas for future smoking cessation interventions within vulnerable groups

Paul CL, Turon H, Bonevski B, Bryant J, McElduff P, 'A cross-sectional survey of experts' opinions about the relative effectiveness of tobacco control strategies for the general population versus disadvantaged groups: What do we choose in the absence of evidence?', BMC Public Health, 13 (2013) [C1]

Bryant JL, Bonevski B, Paul CL, 'A survey of smoking prevalence and interest in quitting among social and community service organisation clients in Australia: a unique opportunity for reaching the disadvantaged', BMC Public Health, 11 827 (2011) [C1]

Walsh RA, Paul CL, Tzelepis F, Stojanovski E, Tang A, 'Is government action out-of-step with public opinion on tobacco control? Results of a New South Wales population survey', Australian and New Zealand Journal of Public Health, 32 482-488 (2008) [C1]

Paul CL, Bonevski B, Bryant JL, Sanson-Fisher RW, 'Approaches to tobacco control and population effects: how good is the evidence that standard approaches are equitable', 12th Annual Meeting of the SRNT Europe Programme (2010) [E3]

20166 grants / $2,357,690

Health care systems could potentially make substantial savings by offering cytisine instead of nicotine replacement products, bupropion and varenicline. However, a direct comparison between varenicline and cytisine was identified as a significant gap in the literature. Our proposed evaluation will determine if cytisine offers equivalent effectiveness to varenicline at much lower cost.

Research Supervision

Number of supervisions

Total current UON EFTSL

Current Supervision

Real-Time Video Counselling for Smoking CessationPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

2016

PhD

Smoking Cessation Care for Australian Cancer Patients: Exploring Current Practices and Potential for ImprovementPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

2016

PhD

Evaluating the Effectiveness of Thrombolysis Implementation in Stroke (TIPS): A Cluster Randomized Controlled Trial in Acute StrokePhD (CommunityMed & ClinEpid), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

Understanding the Impact of Stigma in Lung Cancer: An Exploration of Patient ExperiencesPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

2012

PhD

Improving Pain Management Outcomes in Australian Primary CarePhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

2011

PhD

Prevalence and Clustering of Health Risk Factors Among Patients Attending an Aboriginal Medical ServicePhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

Past Supervision

Year

Level of Study

Research Title / Program / Supervisor Type

2016

PhD

Multiple and Severe Forms of Socioecomonmic Disadvantage and Tobacco Use: Exploring the Factors that Contribute to Smoking Amongst Clients of Community Service OrganisationsPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

2016

PhD

Understanding Consumers' Preferences for Health Service Change: Measures to Inform the Development of Patient-centred Interventions in Chronic Disease Ambulatory ClinicsPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

2014

PhD

An Exploration of Socioeconomically Disadvantaged Smokers' Responses to Three Tobacco Control StrategiesPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

2012

PhD

Colorectal Cancer Screening Participation and Medical Advice Seeking for Symptoms in AustraliaPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

2012

PhD

Tackling Tobacco: An Exploration of Social and Community Service Organisations as a way of Reaching the Socially Disadvantaged for Smoking CessationPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

2010

PhD

Active Telephone Recruitment of Smokers into a Randomised Controlled Trial of Quitline SupportPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

2009

PhD

Smoking Care Provision in Hospitals: A Study of Prevalence and Initiatives to Increase Care DeliveryPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastleCo-Supervisor

2007

PhD

Palliative Care in Australia: Perceptions and Practices of Cancer Specialists and General PractitionersPhD (Behavioural Science), Faculty of Health and Medicine, The University of NewcastlePrincipal Supervisor

Research Collaborations

The map is a representation of a researchers co-authorship with collaborators across the globe. The map displays the number of publications against a country, where there is at least one co-author based in that country. Data is sourced from the University of Newcastle research publication management system (NURO) and may not fully represent the authors complete body of work.

News

University of Newcastle behavioural scientist Associate Professor Christine Paul will work with Cancer Council NSW, Cancer Council Victoria and HMRI to help ensure that distressed cancer patients and their families receive the best possible health counselling when they phone for support.

Associate Professor Christine Paul

Position

NHMRC Career Development FellowshipHealth Behaviour Research groupSchool of Medicine and Public HealthFaculty of Health and Medicine